Bringing hospital care closer to patients amidst COVID-19

On March 14, 2020, Spain declared a state of alarm and lockdown measures due to the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). From that day, COVID-19 changed the practice of oncological care across the country, affecting our comprehensive cancer centre in Madrid, one of the hardest hit cities by the pandemic to date. During those days, when it became clear what was coming, we felt fear and uncertainty. Would we be able to take care of our patients? Would they suffer from COVID-19 more severely than non-cancer patients? There were too many questions with no answers.

I have attended Mr A, a gentleman aged 76 years with chronic lymphocytic leukemia (CLL), for many years. He needed to start therapy with ibrutinib, an oral BTK inhibitor, and had an appointment scheduled at our clinic 1 week after the state of alarm was declared. He was reluctant to attend the visit because of the fear of contagion. The confinement rules limited his transport options. What could we offer Mr A so that he could continue his treatment plan? Would it be safe to delay the start of therapy? These questions came to our mind for every patient.

Patients with haematological malignancies are vulnerable to COVID-19, at higher risk of acute respiratory distress syndrome and mortality. At our centre, specialists managing patients with cancer rapidly adjusted practices to mitigate the potential risks of COVID-19. Telemedicine was considered as an option to support patients by minimising the number of hospital visits and avoiding exposure to COVID-19. We decided to implement four telemedicine strategies in our institution: activating a patient portal for patients to keep in touch with the medical team; providing a lymphoma-related and COVID-19-related symptoms questionnaire to complete at home and complement teleconsultations; granting all patients access to a patient-reported outcome programme to provide information on patients’ wellbeing and patient-centred care; and launching a new drug home-delivery system.

Mr A was a keen and active user of the patient portal, which helped us provide him with adequate care during this crisis. One of the concerns we had in relying on the patient portal was accessibility; however, less than 10% of patients did not have access. The main accessibility barrier was language for non Spanish-speaking patients, rather than access to the internet. To these patients, we offered an appointment delay or in-person consultation. We were also concerned about the impossibility of carrying out an appropriate clinical examination, which often reveals early signs of complications, via teleconsultation. To overcome this issue, all our patients received a questionnaire designed to detect lymphoma and COVID-19-related symptoms. Patients reporting severe symptoms were invited to a phone consultation and, if needed, an in-person visit. For those requiring in-person care, a PCR test was done to allocate patients to COVID-19 or COVID-19-free areas, minimising in-hospital contagions.

Using telemedicine, we can more easily and frequently check whether patients adhere to recommendations by sending them online checklists or questionnaires. We regularly used our patient portal to send questionnaires for close monitoring of symptoms, adverse events, and quality of life. We also embedded the patient-reported outcome (PRO) and experience surveillance programme, which started in our centre in December, 2019, in teleconsultations with patients with lymphoma and CLL. This programme uses PRO tools to assess the value of personalised care. Receipt of regular online tasks can be burdensome for patients and physicians. The completion rate of patient tasks in our centre was 50%; however, patient satisfaction was high (70%).

Finally, to avoid arranging hospital visits to refill prescriptions, our pharmacy department implemented a home-delivery system to send prescriptions directly to patients’ homes. This is of particular interest for patients such as Mr A, who are receiving oral therapy.

Through this programme, Mr A was kept away from the hospital and avoided COVID-19 exposure without affecting the quality of his care. This experience makes us wonder whether telemedicine, sometimes perceived as a threat to quality care in oncology, is actually an opportunity to revolutionise clinical practice moving forward.

For more on COVID-19 in patients with hematological malignancies see Br J Haematol 2020; 190: e16–20

For more on the management of cancer patients during the COVID-19 pandemic see Oncologist 2020; 25: e936–45

For more on telemedicine for patients with haematological malignancies see Future Oncol 2020; 16: 1225–27

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